Incorrect Reimbursement: E/M Downcoding
For incorrectly denied or underpaid Original bills, DaisyBill advises filing a Second Review and including IBR decisions as supporting documentation.
For help determining the correct level of E/M code code and documentation, read DaisyBill’s Work Comp FAQ article: E/M Code Determination: How do I know the right code level for E/M services?
Official Medical Fee Schedule
EOR Denial Reason
The documentation does not support the level of service billed. Reimbursement was made for a code that is supported by the description and documentation submitted with the billing.
Second Review Reason (SBR-1 Form)
Recommended Reason (example of 99214 incorrectly downcoded to 99213)
This CPT was paid at a lower rate than documented in the provided medical records. Per the 1995 AMA CPT guidelines, two of three key components (history, examination, and medical decision making) determine established patient evaluation and management (E/M) level. In the case where counseling and/or coordination of care dominates the physician/patient encounter, time is the controlling factor to qualify for a particular level of E/M service.
The medical records document the time spent face-to-face with the patient, a detailed history was done, review of previous records and recently obtained records and required medical decision making. These factors indicate that 99214 is the appropriate level of reimbursement.
Optional: Attached is a copy of an OVERTURN IBR decision, including the guidelines used to evaluate appropriate 99214 E/M level. This IBR decision indicates that this reimbursement will be overturned when reviewed by IBR.
Recommended Supporting Documents (IBR Decisions)
- IBR Case Overturn Downcode of CPT 99205
- IBR Case Overturn Downcode of CPT 99204
- IBR Case Overturn Downcode of CPT 99214
- IBR Case Overturn Downcode of CPT 99215
Webinar: Request for Second Review
Webinar: Second Review Strategy Kit, Part I
Webinar: Second Review Strategy Kit, Part II
Every request for Second Review submitted from DaisyBill is compliantly submitted using both a completed DWC Form SBR-1, as well as a compliant modified CMS 1500.
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